1
Q
Situation: Part II of the training involves presenting a hypothetical situation to apply the concepts learned during the didactic training. A group was given a scenario of a pregnant woman in the OB ward.
1. The scenario states that the nurse is discussing the nursing process with a newly hired nurse. Which of the following describes the planning phase of the nursing process?
A. Identify the nursing diagnoses
B. Gather information of the patient’s problem has been resolved in the evaluation phase
C. Review the patient’s history during the assessment
D. Prioritize patient problems
A
D
2
Q
- Nurse Peter, one of the group leaders, reviews the steps of the nursing process with his group. Which of the following should he identify as objective data? (Select all that apply)
I. Respiratory rate is 22/min
II. Feels pain after a 10-minute walk
III. Pain is rated as 3 on a scale of 10
IV. Skin is pinkish in color, warm, and dry
A. II and IlI
B. I and IV
C. Ill and IV
D. I and II
A
3
Q
- A pregnant mother delivered a live baby girl. On the second postpartum day, she complains of leg pain. The nurse checked the patient’s chart and noted an order for Ponstan 500 mg every 4 hours PRN for pain, and administered the medication. After 40 minutes, the patient was relieved. What step of the nursing process should the nurse have conducted?
A. Assessment
B. Planning
C. Evaluation
D. Intervention
A
4
Q
- According to the nursing process, which action should the nurse take if the patient’s pain is not adequately relieved?
A. Wait for more time for the pain reliever to take effect.
B. Collect additional data as to why the patient has not been relieved of pain.
C. Teach the patient relaxation breathing techniques.
D. Refer to attending physician.
A
B
5
Q
- During a discussion on the elements of documentation, the nurse trainer asks: Which of the following refers to being comprehensive and timely?
A. Complete and current
B. Accurate and concise
C. Organized
D. Factual
A
A
6
Q
Situation: Mrs. Usagi, a multigravida at 20 weeks of gestation, comes to the community clinic with complaints of dizziness, vertigo, and heartburn. After the physical assessment, Nurse Kuina notes that the patient is malnourished.
6. Usagi was prescribed with iron supplements due to her low hemoglobin level. Which of her statements would indicate correct understanding of the health teaching?
A. My body has all the iron it needs and I don’t need to take supplements.
B. Meat does not provide iron and should be avoided.’
C. “The iron is best absorbed if taken on an empty stomach.”
D. “Iron supplements will give green color to my stool.”
A
D
7
Q
- To prevent maternal anemia, Usagi was given iron supplements. She asks the nurse if her regular intake of Vitamin C will interfere with the prescribed supplements. Which of the following would be the best response of the nurse?
A. “Take two other vitamins separately.”
B. “Take the irons after a full meal.”
C. “Absorption of iron is enhanced with Vitamin C.”
D. Drink milk when taking the iron supplement.”
A
C
8
Q
- Usagi was also advised to begin calcium supplementation during her 2nd and 3rd trimesters of pregnancy. To improve the absorption of calcium, she should take it together with which of the following?.
A. Fat-soluble vitamins
B. Proteins
C. Minerals
D. Water-soluble vitamins
A
A
9
Q
- Nurse Kuina observed that Mrs. Usagi has a knowledge deficit regarding fetal nutrition. Nurse Kuina as to explain that the main source of nutrition for the baby is which of the following:
A. Amniotic Fluid
B. Uterus
C Placenta
D. Chorionic Vill.
A
C
10
Q
- Nurse Kuina gives health teaching to a patient experiencing heartburn. Which of the patient’s statement indicates a need for further instructions? “I have to
A. Drink milk between meals
B. Eat, small, frequent meals
C. Avoid fatty or spicy foods
D. Lie down after eating
A
D
11
Q
Situation: Patient Annabeth, a 28-year-old primigravida, is admitted to a birthing center. She has been in labor for 10 hours. Nurse Clarisse notes that her contractions are hypotonic, occurring every 5 minutes. Annabeth complains of more intense back pain than abdominal pain. Sonogram reveals that the fetus is “borderline” large for gestational age and positioned occipito-posterior.
11. During contractions, Annabeth cries out in severe pain. Nurse Clarisse assesses that her contractions are irregular in frequency and short in duration. Which of the following interventions is BEST performed by the nurse?
A. Try to divert attention from pain.
B. Administer pain reliever as ordered.
C. Stay with the patient and offer her a back rub.
D. Document and report frequency and duration of contractions.
A
C
12
Q
- The physician plans to augment Annabeth’s labor with oxytocin. Which of the following findings should prompt Nurse Clarisse to question this order?
A. She had an amniocentesis performed during pregnancy.
B. Her fetus is large for gestational age by a sonogram.
C. Her membrane ruptured after only 1 hour of labor.
D. Her blood pressure is slightly elevated above normal.
A
D.
13
Q
- Which of the following nursing interventions would be the LEAST appropriate for the nurse to implement for patient Annabeth, who is receiving an oxytocin drip?
A. Know how to recognize potential adverse reactions
B. Administer oxytocin drug with caution
C. Monitor patient closely when infusing oxytocin
D. Inform patient about potential complication
A
D.
14
Q
- When assessing Annabeth
after oxytocin administration, Nurse Clarisse observed that her
contractions have a duration of 70 seconds and it occurs every 90 seconds. What should be the nurse’s INITIAL action?
A. Give an emergency bolus of oxytocin to relaxed the uterus.
B. Discontinue the administration of the oxytocin infusion.
C. Increase the rate of client’s IV infusion.
D. Ask client to turn to her left side and breaths deeply.
A
B
15
Q
- Nurse Clarisse is monitoring the patient. Which finding would indicate that the contraction pattern is adequate？
A. Three to 5 contractions in a 10-minute period, with resultant cervical dilatation.
B. Four contractions every 5 minutes, without resultant cervical dilatation.
C. One contraction every 10 minutes, without resultant cervical dilatation.
D. One contraction per minute, with resultant cervical dilatation.
A
A
16
Q
Situation: A postpartum patient is being cared for by Nurse Chishiya. Routine postpartum care is rendered to the patient.
16. The nurse suspects a postpartum hemorrhage when he assessed that the blood loss is
A.
Less than 300mL/24 hours
B.
More than 400mL/24 hours
C.
Less than 200mL/24 hours
D.
More than 500mL/24 hours
A
D
17
Q
- The mother is asking why she has a gush of blood coming out from the vagina when she first arises from bed. The nurse’s CORRECT response should be
A.
“Blood pools at the top of the vagina and forms clots that are passed upon rising or sitting on
the toilet”
B.
“Positioning causes blood to flow out when she stands.”
C. “Because of the normal pooling of blood in the vagina when the woman lies down to rest or sleep.”
D.
“Normal physiologic occurrence that results as the body attempts to eliminate excess fluids.”
A
C
18
Q
- Within 2 to 3 days after birth, which of the following is caused by the markedly distended uterus and intermittent uterine contractions?
A. Retained placenta
B. Uterine atony
C. Afterpains
D. Boggy uterus
A
A
19
Q
- During the postpartum period, some mothers experience difficulty voiding due to edema and trauma to the perineum. Which PRIORITY nursing interventions can help stimulate the sensation of voiding?
A. Encouraging her to void.
B. Running water in the sink or shower.
C. Helping the mother into the shower.
D, Providing cold tea or fluids of choice.
A
B.
20
Q
- A care plan is being prepared for the mother. According to Ramona Mercer’s Become A Mother (BAM) theory, which of the following statements fosters the process of becoming a mother?
A. The woman becomes comfortable with her identity as a married individual.
B. It encompasses the dynamic transformation and evolution of women’s persona.
C. A woman learns mothering behavior prior as early as a teenager.
D. It accurately reflects the transitional process from being single to a married relationship….
A
21
Q
Situation: Patient MJ, a student from a local university, is admitted to the hospital with severe pre-eclampsia. Despite being instructed to rest, she insists on continuing her studies. The patient studies for 10 hours a day. She also receives frequent visits from her classmates, friends, and family.
- Nurse Gwen is concerned about the patients welfare and her compliance to the doctor’s
instructions. What should be the APPROPRIARTE action of the nurse?
A.
Include a significant other in helping the patient understand the need for rest.
B.
Instruct the patient that the baby’s health is more important than her studies at this time.
C.
Develop a routine with the patient to balance her studies and her rest needs.
D.
Ask her why she is not complying with the prescription for bed rest.
A
C
22
Q
- Patient MJ, who appears to be irritated with the nurse said, “I don’t want to talk to you because you’re only a nurse. I will wait for my doctor.” Which of the following is an APPROPRIATE response by the nurse?
A.
“I’m angry with the way you dismiss me.”
B.
“So then you would prefer to speak with your doctor?”
C.
“I understand. I should call your doctor.”
D.
“Your doctor prescribed this for us to do nursing care.”
A
B
23
Q
- After their conversation, Nurse Gwen is now in a dilemma. This occurs when
A.
There is a conflict between the nurse’s decision and that of his/her superior.
B.
Choices are unclear.
C.
There is a conflict of two or more ethical principles.
D.
A decision had to be made quickly under a stressful situation.
A
C
24
Q
- Which ethical principle stipulates that the nurse has the responsibility to provide all patients with appropriate care, attention, and information?’
A. Beneficence
B. Advocacy
C. Nonmaleficence
D. Veracity
A
A.
25
25. Which of the following nursing action ensures a safe environment for a patient with pre-eclampsia?
A. Maintain fluid and sodium restrictions.
B. Turn off the room lights and draw the window shades.
C. Encourage visits from family and friends for psychosocial support.
D. Take the patient's vital signs every 4 hours.
B
26
Situation: A postpartum mother has just delivered her baby via normal spontaneous delivery. She repeatedly asks the nurse about the basic physiologic changes that occur as her body returns to its pre-pregnant state.
26. The nurse explains that the process by which the uterus returns to a nonpregnant state after childbirth is called
A. Catabolism
B. Subinvolution
C. Contraction of muscle fibers
D. Involution
D
27
27. The nurse explains to the mother that the uterus will return to its pre-pregnancy state in weeks.
A. Six
B. Three
C. Four
D. Five
A
28
28. The nurse explains to the patient that the primary factor contributing to delayed uterine involution is which of the following conditions?
A. Full bladder during labor
B. Lack of exercise during pregnancy
C. Prolonged labor and difficult birth
D. Infection during pregnancy
C
29
29. When assessing the uterine fundus of the postpartum mother, which part of the abdomen should the nurse start to palpate?
A. Symphysis pubis
B. Midline
C. Umbilicus
D. Sides of the abdomen
C
30
30. During the immediate postpartum period, the PRIORITY nursing intervention is focused on
A. Monitoring urinary output
B. Taking the vital signs every 4 hours
C. Observing postpartum hemorrhage
D. Checking level of responsiveness
C
31
Situation: Tori, a postpartum patient who delivered a stillborn, wants to leave the hospital without a physician's order. She is currently on close postpartum monitoring and remains hooked to an intravenous fluid infusion.
31. Which of the following is an APPROPRIATE action by Nurse Andre to avoid liability?
A. Notify nursing supervisor of the patient's plans to leave
B. Arrange medication prescriptions at the patient's preferred pharmacy.
C. Notify directly the attending obstetrician.
D. Ask the patient about transportation plans from the hospital.
32
32. Patient Tori requires early ambulation. Which of the following instructions given by Nurse Andre is INCORRECT?
A. Assist the patient from sitting to standing position.
B. Raise the head of the bed slowly to achieve sitting position of the patient.
C.Allow the patient to rise from the bed to a standing position unassisted.
D. Assist patient to rise from lying to sitting position..
C
33
33. As Nurse Andre awaits the nurse supervisor's response to the patient's request for discharge, she decides to check on the patient. Upon entering the room, she notices that the wastebasket is on fire.
Arrange the nurse's actions in the correct order.
I. Rescue the patient.
II. Activate the fire alarm.
III. Close the door to confine the fire.
IV. Put off the fire with fire extinguisher.
A. IV, II and I
B. I, II, III and IV
C. I, Il and IV
D. II, IV and I
B
34
34. After the fire was extinguished, it was discovered that the patient had absconded. What is the ethical and legal responsibility of the attending nurse?
A. Autonomy
B. Nonmaleficence
C. Beneficence
D. Justice
B
35
35. Absconding is inevitable in any health care facility. If it is discovered that the patient has absconded, who should be notified IMMEDIATELY?
A. Attending physician
B. Security guard on duty
C Resident on duty
D Nursing staff...
B
36
Situation: One of the responsibilities of the nurse is to administer prescribed medications. Nurse Anne is assigned to the pediatric ward.
36. Prior to administering the drug ordered by the pediatrician, Nurse Anne needs to know if she is giving the prescribed medication to the right patient. The FIRST step is to
A. Check the patient's hospital bracelet.
B. Ask the parent/significant other to state name of patient and birth date of patient
C. Verify patient's allergies with chart and with patient
D. Compare medication order to identification bracelet.
B
37
37. When administering medication to pediatric patients, dosage vary. Which of the following factor should Nurse Anne consider in determining the right dose
A. Height and surface area
B. Size, surface area and age
C. Size, surface are, age and height
D. Size and surface area
D
38
38. Which part should Nurse Anne often use for intramuscular injection in infants and toddlers to reduce the risk of vascular and peripheral nerve injuries?
A. Gluteus maximus
B. Dorsogluteal
C. Deltoid muscle
D. Vastus lateralis
D
39
39. Comprehensive survey of research reports reveal that intramuscular medication administrations may cause several serious adverse effects. When the head nurse asks Nurse Anne about the MOST common complication that may arise, she should mention
A. Abscess
B. Nerve palsies and paralysis
C. Hematoma
D. Muscle contracture
D
40
40. The head nurse evaluates Nurse Anne's knowledge of administering oral medications to pediatric patients. Which of the following statements below should she choose as CORRECT?
A. A child's reaction to a dose ordered by a physician is not less predictable than adult's reaction.
B. When giving oral medication, the child as young as two years of age cannot be taught to
swallow drugs.
C. The child should be told to place the tablet in the middle of his tongue and drink water to wash
down the tablet.
D. The possibility of error is greater in the giving of medication to children than to adults.
41
Situation: Bianca, a 1-year-old girl, was brought to the hospital and diagnosed with pneumonia. She is receiving IV antibiotics, antipyretics, and decongestants, along with vitamin supplementation. At
present, she is also undergoing oxygen therapy.
41. Nurse Nico is concerned because Bianca refuses to take her prescribed oral medication. What would be the most appropriate way for the nurse to address this situation?
A. Leave the child alone
B. Seek the help of the mother in giving the oral drug.
C. Mix the drug with milk to cover up the unfavorable taste.
D. Get angry with the mother and the child.
B
42
42. Recognizing the normal developmental behavior of a 1-year-old, Nurse Nico understands why Bianca continuously refuse to take her drug. It is because it is normal for her age to
A. Have separation anxiety.
B. Internalize the attitudes of others.
C. Utilize magical thinking.
D. Be negativistic in all matters.
D
43
43. When administering IV antibiotic therapy to Bianca, the nurse should use which IV cannula gauge most commonly?
A. 20
B. 24
C. 22
D. 18.
B
44
44. What is the BEST method for administering oxygen to Bianca?
A. Hood
B. Face Mask
C. Incentive Spirometer
D. Nasal catheters
D
45
45. Which evaluation parameter is the MOST IMPORTANT for Nurse Nico to monitor in determining whether Bianca's condition is improving?
A. Absence of fever
B. Absence of chest indrawing
C. Respiratory rate of 45 beats per minute
D. Respiratory rate of 55 beats per minute
A
46
Situation: Katarina, a five year-old child was admitted to the pediatric ward with complaints of severe otalgia, fever, and irritability. According to the mother., the child experienced upper respiratory infection, three weeks before admission. The admitting diagnosis is acute otitis media (AOM).
46. During Nurse Jade's INITIAL assessment of Catarina, the child is crying persistently and frequently pulling at her right ear. What would be the nurse's MOST APPROPRIATE action?
A.
Request parent to carry the child
B.
Take Catherine's vital signs.
C.
Refer to the attending physician.
D.
Assess the description and frequency of pain.
C
47
47. Based on her knowledge of acute otitis media, Nurse Jade recalls that children are predisposed to this condition due to the following risk factors, EXCEPT:
A. Absence of breastfeeding
B. Swimming
C. Exposure to cigarette smoke
D. Poor hygiene
B
48
48. As ordered by the physician, Nurse Jade prepares to administer Ofloxacin eardrops to Catarina. To prevent dizziness, she warms the bottle in her hands before instillation for how many minutes?
A. 5 to 6 minutes
B. 1 to 2 minutes
C. 3 to 4 minutes
D. 6 to 7 minutes
B
49
49. After handwashing and gently cleaning any removable discharge from the child's outer ear, Nurse Jade positions the child. Which of the following steps should she do next?
A. Gently press the tragus of the ear four times in a pumping motion.
B. Gently pull the outer ear
C. Drop the medicine into the ear canal.
D. Keep the ear up for five minutes.
B
50
5. To promote drainage and relieve pressure caused by fluid accumulation, Nurse Selma shoul nstruct the child to assume any of the following positions, EXCEPT
A Tilt head to the side if sitting up
B. Lie on the affected ear
C. Put the pillows behind the head
D. Lie on the non-affected ear.
D
CLOSE DOOR PART A & B
flashcards
Decks in class (5)
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